Motivational Interviewing

Motivational interviewing is an evidence-based, directive counseling approach to helping people make changes in harmful or risky behaviors. It is a method used to enhance a person’s intrinsic motivation to change by exploring and resolving ambivalence and building confidence. Motivational Interviewing is a client-centered approach that can be used effectively as a strategy to help people make changes related to smoking, substance use, health and nutrition, mental health, and other issues.

Problem or Challenge:

Many people who experience homelessness face challenges related to health, mental health, substance use, exercise, or other conditions or problems that can be managed more effectively only with changes in habits. Change is difficult, and often people are ambivalent about it. Unfortunately many service programs are not designed to accept and work with people who feel ambivalent about change. Some programs require that people have a strong commitment to change before they can participate in treatment or other recovery support services. These requirements create barriers to access for people if they are not already highly motivated to change their diets, or stop smoking, drinking, or engaging in other harmful or risky behaviors. When people experience long-term homelessness, or long-term problems related to substance use or mental illness, they often become isolated and separated from ordinary activities, relationships, and a sense of place and purpose in the world. The longer a person remains homeless the more likely he or she is to feel disaffiliated from others and hopeless about the possibility of change.

Solution:

Motivational interviewing has been proven effective at providing people with the motivation and confidence they need to change their lifestyles and instill healthier habits. Motivational interviewing has four core principles:

Express empathy: the counselor creates an atmosphere in which the client can safely explore conflicts and face difficult realities. The counselor uses reflective listening and seeks to understand the client’s feelings and perspective without judging, criticizing or blaming, while recognizing that ambivalence is normal.

Roll with resistance: the counselor avoids arguing for change, instead using resistance as a signal to respond differently. The counselor offers new perspectives but does not impose them. The client is the primary resource in finding answers and solutions.

Develop discrepancy: When a person’s own behavior conflicts with important personal goals, change is more likely to occur. The counselor uses and amplifies discrepancy between goals and behaviors to help the person explore the importance of change for him or her. The goal is to have the client present the reasons for change. The counselor elicits and reinforces change statements that include recognition of the problem, expression of concern, intention to change, and optimism for change.

Support self-efficacy: The goal is to build the client’s confidence in his or her capacity to cope with obstacles and succeed in change. The counselor helps the client to plan for and begin the process of change. Recognition that even small, incremental changes are important helps to build a person’s confidence and strengthen the commitment to change.

Open-ended questions, affirmations, reflective listening, and summary reflections (OARS) are the basic skills and techniques used “early and often” in Motivational interviewing. Open-ended questions encourage people to tell their story, and are used to gather information and establish rapport. Affirmations recognize client strengths and acknowledge behaviors that lead in the direction of positive change, no matter how big or small. Affirmations build confidence in one’s ability to change. Reflective listening is a skill used to build trust, engage others in a relationship, and foster motivation to change. Summaries are a type of reflective listening used to help ensure clear communication and provide a stepping stone toward change.

The counselor uses a directive strategy to get a client to talk about change and to help a client explore and resolve ambivalence about change. If the counselor advocates for change, the client may be put in the position of defending against it. Instead, the counselor facilitates the client’s “change talk” by encouraging the client to present the arguments for change.

Implementation Steps/Tips:

Train ALL staff in Motivational interviewing. Some organizations have found that Motivational interviewing is a useful tool to use in changing their program models and organizational culture to better engage and serve people who experience homelessness. Staff members who come from different disciplines (medical, behavioral health, case management, employment, administration, and housing) can and should understand why people are often ambivalent about change. They can use the language of Motivational interviewing to reinforce values, create shared vocabulary, and coordinate the approach across their organization.

Outcomes/Results:

Motivational interviewing produces positive treatment outcomes, including reductions in problem drinking or other drug use, and improvements in consumer engagement and retention in treatment, health care, and recovery support services. When workers are provided with training and support to use the skills and strategies of motivational interviewing, there is more satisfaction and job retention, and less burn out and attrition. Motivational interviewing strategies reduce confrontations between staff and consumers, and reduce the rate of no-shows or drop-outs.

Motivational interviewing is listed in SAMHSA’s National Registry of Evidence-Based Practices and Programs (NREPP) and a summary of the research evidence is available online.

A webinar about Motivational interviewing and links to a variety of resources are available from the SAMHSA-HRSA Center for Integrated Health Solutions (CIHS). CIHS is funded jointly by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Health Resources Services Administration (HRSA) to promote the development of integrated primary and behavioral health services to better address the needs of individuals with mental health and substance use disorders.

SAMHSA’s Mid-Atlantic Addiction Technology Transfer Center Network (ATTC) has created the Motivational interviewing website, which contains links to manuals, on-line courses and other training resources including video and multi-media training materials, and a bibliography. Some training materials available on this website focus on motivational interviewing strategies that are effective for serving people who are members of Native American/Alaska Native communities.

The National Health Care for the Homeless Council provides on-line training that includes video instruction and written materials. The training is primarily designed for health care providers, social workers, mental health and substance abuse counselors who provide outreach and care for persons experiencing homelessness. Additionally, other employees or volunteers would also benefit from this training.